• Important points in conducting an interview with children and adolescents
• Communication with parents and children
• Important aspects of the history include birth and perinatal problems, dietary intake, development, vaccination, travel, family and social history
• Special aspects of physical examination:

• In the general examination of the child much can be learned from simple observation:

• Examination of the systems cardiovascular, respiratory, abdominal, neurological and development

• To be competent in taking a history of the symptoms and signs of a presenting illness and review of the course and nature of past illnesses, the family history and a review of the systems.
• To be aware of basic skills in communicating with the parents and patients.
• To be aware of the general principles of physical examination of children of different ages.
• To be able to observe and recognise common physical signs and to perform a general examination of the paediatric patient
• To have clearly defined goals of the clinical encounter: identify the problems from the history, formulate a list of differential diagnoses, focus on aspects of the examination most relevant to the clinical problems, establish a diagnosis and formulate a plan of management

• History is usually related by an intermediary, usually a parent or caretaker.
• The traditional history taking process and physical examination is often blurred in paediatric interview.
• Observation of the child and family begins in the waiting room and during the interview—relationship between parents and child, reaction to stress and separation, the appearance of the child, state of dress, hygiene, ethnic origin and social class.
• The paediatrician and parent/patient must have time to establish a rapport that facilitates the exploration of psychosocial information.
• The interview should be conducted in a setting of privacy.

• Offer parents and teenagers some time during the encounter to express their concerns separately and in private.
• Parents and patients should be advised about the paediatrician's position concerning confidentiality.
• The nature of the adolescent’s complaints often requires communication with the school, other institutions or previous physicians and this should be explained and permission obtained from the patient and parents.
• Adequate time allocation for interview.
• Session summary is often helpful (to clarify and to allow the patient to express concern).
• For some adolescent patients, the concept of contract is helpful.

• Introduce yourself to the patient and the parents and most families respond positively to a physician who is warm, friendly, non-condescending in attitude and concerned about their child and their anxieties.
• Give parents plenty of opportunity to give a spontaneous account of the child’s illness and to express their concerns on the child’s presenting complaint
• Time should be spent exploring the emotion and social consequences of the illness and the reaction of the family to the illness (especially in cases of chronic illness).
• Particular care must be taken when parents are angry or displeased with a previous physician or health professional
• The paediatrician must be aware of his/her own prejudices and vulnerabilities and strive to maintain objectivity
• Sustain eye contact.
• Use lay terms to communicate with parents.
• The paediatricians should have their own stock phrases that will facilitate communication:

1. What had you hoped we could do for your child today?
2. I would like to understand your reason for that (idea, feeling, behaviour)? Can you explain?
3. There is a lot of conflicting opinions about (example) and here is an approach that has been found to be useful
4. I strongly recommend that you…

• The paediatrician should be aware of the non verbal aspects of communication, facial expression, tone of voice, attitude or gestures may influence the parents perception of the message
• Interject the interview with empathic and supportive comments.
• Continue a logical flow of contents.
• The paediatrician should be aware of the non-verbal aspects of communication, facial expression, tone of voice, attitude or gestures may influence the parents’ perception of the message.
• The paediatrician must be aware of his/her own prejudice and vulnerabilities and strive to maintain objectivity.
• Particular care must be taken when parents are angry or displeased with a previous physician or health professional.

• The age of the child determines the level of verbal communication but important non-verbal communication takes place between the paediatrician and the child beyond early infancy.
• Do not talk to children in a condescending way.
• Do not convey to the child that his or her feelings and idea and concerns are childish.
• Do not laugh at a child or tease a child.
• Initial casual encounter with your children are often made easier when introduced in a soft voice and speak to a child on the same level.
• Older children should be given the chance to tell the paediatrician his/her symptoms.
• Children need continually to know what is happening and what is going to happen to them.

• General activity, feeding and appetite
• Difficulty in swallowing, vomiting, abdominal pain and distension, state of the bowel and character of the stools, gain or loss in weight and jaundice
• Discharge from the eyes, ears, nose, cough, shortness of breath, stridor/wheeze, breathing pattern
• Cyanosis, breathless and sweating on feeding or exertion, oedema
• Thirst, polydipsia, polyuria, dysuria, frequency, haematuria, enuresis
• Behaviour and mood
• Musculature, posture, gait, co-ordination, involuntary movements, fits, speech, vision and hearing
• Treatment history and allergies
• Vaccination and contact with infectious disease
• History of previous illness
• Travel history
• Social and environmental history
• Family history - parents’ age, size, state of health, consanguinity, known hereditary illness (premature atherosclerosis, HT, diabetes, thyroid disorder, epilepsy and mental retardation)

• Parity and gestation
• Ascertain illnesses which the mother had before and during pregnancy including exposure to drugs/radiation, hydramnios, hypertension, toxaemia, threatened abortion or antepartum haemorrhage and previous obstetric history of abortion, stillbirth, perinatal deaths.
• Duration of labour, mode of delivery, size and condition at birth(Apgar score)
• Immediate post-natal problems and results of neonatal screening(thyroid and G6PD status)

• Social smile (1.5m)
• Reach over for objects (3-4m)
• Roll over from supine to prone (4-5m)
• Sit unaided (7-9m)
• Crawl (7-9m)
• Walk around furniture (9-12m)
• Walk independently (12-15m)
• Single words with meaning (12-15) and chaining words together (18m)
• Toilet trained (24m)
• Upstairs 2 feet/step (24m)
• Downstairs two feet per step and upstairs one foot per step 36m
• School performance

• When parents do not appear readily reassured by the diagnostic and treatment procedures:
• Did the parents understand and what was prescribed or recommended?
• Had the parents been having opportunities to ask questions?
• Parents’ failure to comply with recommendation made for the care of the child.

• Weight
• Supine length, sitting and standing height
• Head circumference
• Skin fold thickness: triceps, biceps, subscapular
• Derived indices: weight for height, ponderal index BMI
• Body proportion and shape change with age
• Use of growth charts
• Pubertal status-pubic hair, testes, penis and breast development

• Undernutrition: low weight for age and weight for height; wasting of muscles and subcutaneous fat; Kwashiorkor – mild wasting, sparse depigmentated hair and skin, dermatitis, skin ulcer, hepatomegaly.
• Obesity: increase in body fat (skin fold thickness>85%, BMI>+2SD) maybe nutritional or organic - Prader-Willi, Lawrence Moon Biedl, Cushing and Down syndrome, hypothalamic disturbances, growth hormone deficiency, hypothyroidism, pseudohypoparathyroidism

• Present with severe life threatening injuries, bruising or injuries as a result of observation by others or incidental findings
• Intracranial injury from direct trauma or shaking-retinal haemorrhages
• Rib fractures posteriorly at costochondral junction, multiple fractures at different stages of healing especially metaphyseal fractures
• Abrasion, bruises, pinches, bites, burns, scalds
• Torn frenulum of the upper lip
• Sexual abuse

Flat bottom

• The length and weight are proportionately low with preserved head growth
• Pale, lethargic, hypotonic with wasting of muscles and subcutaneous fat
• Apathetic (lack of feeling or emotional indifference), withdrawn, radar-like gaze, frozen watchfulness, rarely smiling or vocalising
• Indiscriminately friendly, aggressive egocentric behaviour
• Disorder of sleep and elimination

Less than 5% of children show signs of this. If they do, it is usually a serious condition.

• The child should be placed where he wishes, on the mother’s knees, playing with toys.
• Doctors should be friendly, patient, non-threatening and should not be too conscious of his or her own dignity.
• Procedures required child’s co-operation should be done first eg. Developmental assessment.
• Explain what is to be done in a soft persuasive voice, give age appropriate instructions.
• Avoid asking leading questions (don't ask 'did I touch you?', ask 'where did I touch?')
• May not be possible to follow the usual sequence of IPPA.

• Weight
• Supine length, sitting and standing height
• Head circumference
• Skin fold thickness, triceps, biceps, subscapular
• Derived indices: wt for ht, ponderal index, BMI
• Body proportions and shape change with age
• Use of growth charts
• Pubertal Status (breast, testis, pubic hair)
• Orchidometer: measure testicular volume (pubertal > 4cc)
• Pubic hair: must be from pubis (eg. Not from testicles, labia)
• Breast: 9.8y, menarche 12.4 yr. (average)
• Male puberty: start 8.5y (earlier = abnormal)

• General state of child, colour, hydration, nutrition, activity, posture and movements
• His reaction to environment, interaction with strangers and relationship with parents
• Skin rash – roseola infantum, common childhood infections like measles, rubella, chickenpox
• Viral infections: EBV, EV (Coxsackie, ECHO)
• Bacterial infection, typhoid, pupuric rash of meningococcal and pseudomonas septicaemia, scarlet fever, erythema marginatum
• Reactions to drugs
• Autoimmune disease

• Oxycephaly: top of head pointed or conical owing to premature closure of coronal and lambdoid sutures (aka acrocephaly, hypsicephaly, turricephaly, steeple head or skull, tower head or skull)
• Bradycephaly: "slow" head?
• Microcephaly: abnormal smallness of the head, usually assoc. with MR
• Scaphocephaly: skull is abnormally long and narrow, as a result of premature closure of the sagittal suture, with heavy centres of ossification in the line of the suture; usually accompanied by inflammation and atrophy of the optic papillae and by MR
• Hydrocephaly: developmental obstruction of the CSF pathways resulting in marked dilatation of the cerebral ventricles. Fluid is usually under increased pressure. Characterised by enlargement of the head, prominence of the forehead, brain atrophy, mental deterioration and convulsions
• Megalencephaly: abnormally large brain
• Plagiocephaly: an asymmetric and twisted condition of the head, resulting from irregular closure of the cranial sutures
• Hydranencephaly: complete or almost complete absence of the cerebral hemispheres, the space they usually occupy being filled with CSF

Fontanelle close by 18m, tension, posterior fontanelle size

B = distance between inner points of eyes

A = between outer points of eyes

C = between pupils

• Chinese: often have broad nasal bridge, can cause pseudosquint (B and C normal, A decreased)
• Inflammation around eye area dangerous (ethmoid, paranasal) - periorbital cellulitis must be treated with ABX (not just topical)
• Storage disorder: cloudy cornea, coarse facial features, bushy eyebrows
• Syndactyl: webbed fingers
• If you have 3 or more minor malformations, you have a 90% chance of having major abnormality (urinary tract, heart)

• Down's syndrome (leukaemia)
• Trisomy 18: dismorphic facies, feet, hands, feet like bottom of rockingchair, fingers overlap
• Turner's syndrome: increased carrying angle, webbed necks (50% of children with Turner's syndrome do not have symptoms and signs; usually just a bit small) - deletion of one of the X-chromosomes
• Prader-Willis syndrome: chromosome 15 deleted, micropenis, obese, MR, spindly fingers on small hands
• Noonan syndrome: male equiv. of Turner's syndrome, somatic features of Turner's syndrome, normal chromosomes, neck webbing, increased carrying angle, low-set hairline; deletion of PTPN11
• Hypochrondroplasia: big head, short limbs, milder form of achondroplasia
• Beak nose: Rubenstein-? Syndrome, broad fingers
• Spondyloepiphyseal dysplasia: skeletal dysplasia affecting spine: short trunk, short stature, mature face, shortening of proximal part
• Amniotic fluid bands: fibrous bands in amniotic fluid sever the limbs of the foetus